A Day in the Life of a Critical Care Physician

Session 140

No “typical” days! That’s what hooked this academic critical care physician. So what’s daily life for Dr. Susan Wilcox?

I’m excited to have a great conversation with Dr. Susan Wilcox today, an emergency medicine trained anesthesia critical care trained critical care doc. Now obviously the conversation that they have today is even more important right now as we are in the middle of this COVID-19 pandemic.

I talked to Dr. Wilcox at the beginning of March before all of this really started, and so it doesn’t come up much at all during the conversation. Dr. Wilcox has been out of training now for 11 years and works in the partners healthcare system in Boston.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:30] Interest in Emergency Medicine and Critical Care Medicine

Susan came to the two specialties very separately. She did her third and fourth year in medical school, and nothing really stuck out at her as something she loved. She thought she was going to be an oncologist. She came into medical school totally prepared to go into oncology and that she was going to do internal medicine oncology fellowship. She had it all planned out.

But then she just didn’t love internal medicine. She thought she would like it, but she didn’t love it. And it was the same thing for so many other specialties.

And as she got to emergency medicine, she realized that it was doing a little bit of everything that she really liked. She likes having a patient come in completely undifferentiated that hadn’t been worked out. For her, emergency medicine just felt right because everything clicked.

As she went through the rest of her fourth year of medical school, she was able to shape the rest of that experience.

She had to prepare what she thought was necessary to be a good emergency medicine resident going forward.

Susan definitely came to emergency medicine first. During emergency medicine residency, she started in the pediatric ICU as her first rotation. Now, being a little bit older and wiser and going through the ICU, it was growing on her and she really liked it. She got to know the kids in the ICU, she got to know their families.

And then when she went back to the emergency department, she still loved emergency medicine, but it was just different.

[03:49] High Acuity vs. Longitudinal Care

Susan realized that in the emergency department, she would have these great cases. They would resuscitate patients who would be really proud of the care that they provided. Then they would go upstairs, and she would watch them roll out of the emergency department. Then she’d wonder what’s going to happen next.

Susan wanted to continue the conversation and she wanted to follow them longer. When you’re a student and you’re seeing these patients, every single one of them is exciting, very little scary but it’s novel.

And part of the reason that you do emergency medicine training is so that you don’t feel frightened or nervous or scared when you see those patients.

In one way, some of the excitement and the novelty will wear off with the training, that’s literally what it’s supposed to do. Then the other way is you just feel confident and comfortable taking care of those patients.

It’s as if you’re looking for the adrenaline rush. It definitely does happen in emergency medicine, but, certainly, not that often.

If you have the adrenaline rush all the time in the emergency department, then you’re probably not well trained because it’s not supposed to happen. Instead, it’s really about the fact that the patient comes in and something’s wrong because they come to the emergency department. And it’s up to them to try to figure out why in an expedited manner.

For a lot of patients, it’s really about making a diagnosis. And if you can figure out for some patients, what’s going on, that in and of itself can be so relieving and be a huge part of why they came to the emergency department. And this is a lot of the work that she finds to be very gratifying.

[06:58] The Biggest Myths and Misconceptions Around Emergency Medicine and Critical Care Medicine

One common misconception is that in the emergency department, the only thing clinicians care about is turnover and trying to get patients in and out as fast as possible.

To some degree, there is a real issue with that as they have to get patients moving because there are patients waiting.

Everyone wants to make sure that their patients are well worked up and well treated. That being said, she thinks that the idea that you can get it moving patients through any way is a little bit overstated.

Moreover, critical care is definitely a particular beast. Susan thinks emergency medicine is great preparation for doing critical care later on. However, there’s this idea or this myth now that it is an easier pathway or it’s a well established pathway.

So she still sees so many people who go through doing emergency medicine and critical care. They come out as great clinicians that have a lot to offer. But they really struggle to find their niche and find their place because it is such a very particular skill set and not every institution is going to have opportunities for people to do emergency medicine critical care.

[09:26] Types of Patients

In the intensive care unit (ICU), patients have some sort of critical illness that requires constant monitoring, with specially trained nurses, physicians, pharmacists, respiratory therapists. There’s a whole team approach to take care of these patients because they have something that is literally life threatening going on.

These patients need minute-to-minute monitoring and they may also need invasive therapy.

The common things that would land a patient in the intensive care unit are:

Having respiratory failure to the point of needing a ventilator

Having an endotracheal tube put in

Having some sort of external breathing support

Needing blood pressure medications to keep their blood pressure up

Most commonly, every once in a while, somebody will have a hypertensive crisis or have an issue where their blood pressure is too high. And they need to have their blood pressure brought down.

Certainly, patients who are having acute heart attacks can occasionally have complications that will land them in the intensive care unit, similar to stroke or something like that. Sometimes, the patients if they have severe deficits, will need intensive care.

Depending on what hospital you’re in, there are sometimes different flavors of intensive care units. Examples are the neurology intensive care unit, trauma ICU, cardiac ICU,

For those who don’t know what these different ICUs are, It’s usually an intensive care unit (ICU) preceded by the type of specialty.

There’s the neurology intensive care unit where the patients with the strokes or when their head bleeds or sometimes traumatic brain injury. Sometimes they go to the trauma ICU, but they can go to those units.

Susan does a lot of work in the Cardiac Intensive Care Unit, both taking care of patients who’ve had cardiac surgery, and then patients who are having complications after having heart failure or having an MI or heart attack.

Pediatrics has their own intensive care unit for children who are critically ill. There’s surgical critical care. Some units will blend trauma and surgical patients together in one unit. Some will separate patients who have had surgeries and then are critically ill afterwards.

People can come to critical care as physicians through all different pathways, usually specializing in the specialty. A surgeon can become a specialist in surgical critical care and a neurologist can become a specialist in neurology critical care, etc.

[13:00] Opportunity for Procedures in Critical Care

A part of being a good critical care doctor, or otherwise known as an intensivist, is being able to do procedures to be facile with your hands.

Sometimes patients need something done and they need it done quickly. You have to have both the mindset where you’re going to jump in and do what the patient needs at the moment they need it done and then the technical ability to get the procedures done.

Some of the common ones that have come up in the intensive care unit is airway management for the patient. They’re struggling to breathe who needs an endotracheal tube placed. In central Line placements, they put in an intensive, very large intravenous line that goes usually into the neck, the chest or the groin, into one of the large veins there. This allows for medications to be given directly into the central circulation. It monitors the pressures in the venous circulation as well.

They also do arterial lines where they place a blood pressure monitor directly into an artery. This allows them to monitor the blood pressure, literally beat to beat and follow the blood pressure and follow the effects of our interventions.

Other procedures include thoracentesis where they take fluid off from around the lungs. Or paracentesis where they take fluid off that’s accumulated in the belly, in the case of a patient with cirrhosis. Sometimes patients need chest tubes if they have a collapsed lung, and they have to put a tube to release the air from that space.

[15:41] What the Shift Work Looks for a Critical Care Physician

It really varies upon depending upon where you are. At Susan’s institution, they have gone to shift structure in their intensive care units. That is very analogous to the emergency department.

They realized that their patients are so sick so they want to make sure that they have an attending physician there 24 seven. And the only way to really do that is to have a shift structure, just what they do in the emergency department. So they have somebody who comes in early in the morning, afternoon, and evening to take over each other.

There are definitely intensive care units that have more of the week-on-week-off model. And for some of those they will have, say, seven days. The attending will come on the first day and they will stay until their work is relatively done. And when they feel all the patients are stable enough and everything is talked, they will go home. Sometimes they’re on home call, often they’re on their own home call.

They will kind of keep an eye on the patients and if there’s anything that needs, the intensivist takes calls from home or they come in when the patient is really sick. Then even though they might have been up all night, then the next morning they’re back on and they’re there during the day and they round during the day.

There are some advantages and disadvantages to each model. Having the shift structure can be tough because you’re working seven nights in a row. And that’s a lot of work. Conversely, having seven days where you could also be up almost every night, if not every night, can get also really tiring too.

[18:05] Typical Day

A typical day for Susan is not having one. She’s fortunate to work for three different groups. She works in the emergency department at Mass General. Then she works in the intensive care unit where she does mostly cardiac critical care. Then she also works for Boston MedFlight, where she’s the medical director there.

For example, on the day of this recording, she woke up this morning and she did a bunch of academic work. She worked on some manuscripts and some research projects. She went to a lecture at noon to hear a colleague speak about Medicaid expansion.

In a few hours, she’s going to go in and work overnight in the intensive care unit. So she’s doing a shift tonight in a different unit. It’s a little bit different than the structure she just mentioned. Then tomorrow morning, she has a couple hours of staff meeting, and then she’s going to the residency lectures.

Susan is optimistic she’ll be able to get a couple of hours of sleep on the ICU tonight. And she might be able to sneak in a quick nap tomorrow. But she wants to be very clear that she loves her job.

[19:56] Life Outside of the Hospital

Susan is married. She doesn’t have children, which was a personal choice. But she definitely gets a life outside of the hospital where she does some traveling. And she makes her own clothes which is her hobby.

[20:43] The Training Path to Become a Critical Care Doctor

There are really three that are the most common for the vast majority of ICU. First is through internal medicine, and then doing either pulmonary critical care or just critical care as a fellowship after doing internal medicine. People do anesthesiology, and then they’ll do a critical care fellowship after that. Or they do surgery and then doing a critical care fellowship after that.

Many ICUs have a broad-based hiring policy. Just because you did an internal medicine pathway does not mean that you’re necessarily relegated to doing it. People can move back and forth between the different types of ICUs. Except for neurocritical care because it’s so highly specialized, there’s a little bit more flexibility in moving back and forth different ICUs.

[22:12] Message to DOs about Overcoming Negative Bias

Susan would consider critical care as moderately competitive and she recognizes the bias. But whether you’re an MD or a DO doesn’t really matter.

Regardless of whether you’re an MD or DO, be able to show your interest in this specialty for you to be competitive. It’s really nice if you’re going into your fellowship application, having something special on your application, be it a publication. This doesn’t need to be a New England Journal original research study.

Just be able to show that you’ve written up a couple of case reports that you’ve done, worked with somebody on a review article.

Show that you’re the kind of person who can take a project and get it done and this really says a lot to a program director.

Present a poster at a national meeting. Join some societies and take on some leadership role. This is very doable as a resident. It might sound it’s all of this is so much on top of what you’re expecting residency to be. But most residences will give you some flexible time to engage in these extracurricular activities.

[25:25] What Being a Medical Director Looks Like

Although she works at Boston MedFlight, Susan doesn’t ride helicopters. For one, she has terrible motion sickness. So riding in a helicopter is not all that fun for her. But what she loves is this idea of transporting the very sick patients.

Susan feels lucky to work with some of the best paramedics and nurses in the country working at Boston MedFlight. They transport patients that are incredibly sick who need to get into Boston to get tertiary level care. They need to get that specialized care that they can’t get anywhere else. Susan works with them, writing medical protocols, reviewing cases and doing ongoing medical education, be it lectures.

Nowadays, they do a lot of education by email. They review cases and talk about the updates in the literature. She also leads their research efforts. They’re constantly looking at their processes and figuring out what they do well and what they can do better. They try to figure out how they can share their insights with the rest of the medical community at large.

The clinical work that they do is absolutely incredible. Susan says there are lots of different pathways. They have associate medical directors who have come through emergency medicine. They’ve had people who have come through anesthesia and then done critical care. People have done surgery and critical care.

Susan adds it’s great to have a little bit of that understanding of the emergency medical services (EMS) background that you get with emergency medicine. As well, it’s great to also have an understanding of how intensive care units work, what critical illness looks, and what the patients need. It’s a great mix if you want to have a future working in critical care transport.

[28:23] Are there Critical Care Physicians in the Aircraft

In the United States, they have a slightly different model. The military model has a strong physician support on the civilian side. In the United States dominantly, it is paramedic and nurse transport teams. That being said, their paramedics and nurses have extensive experience.

They have to show that they have worked in a high volume, high acuity environment for several years before they can even apply to work at Boston MedFlight.

Then they’d have to undergo another extensive orientation period where they’re trained on their protocols and their standards of care. They do in depth case reviews to make sure that they have ongoing continuing medical education and that they’re doing everything as optimally as possible.

With that system, Susan thinks that they provide excellent care without a physician on board. And this is pretty common in the United States. There are definitely some cities where physicians are more involved in the transports such as Cincinnati. Madison, Wisconsin has a physician based transport system. It’s kind of sprinkled throughout the country.

They let physicians do ride alongs but for the most time they do this, it’s usually more for the physicians benefiting than for the patients.

It’s actually a reimbursement issue of just paying for a physician to be there because they don’t really need to be there.

Insurance companies don’t think they need to be there. Doctors are expensive. So if you don’t have to have a doctor on your flight, then it may not be cost effective.

Nevertheless, Susan is very proud of the excellent care provided by the nurse paramedic teams. In fact, she’d be happy to have herself or anyone she loves to be transported by one of them. That being said, it’s a little bit controversial.

In Europe and with the military models, they have physicians on board and they provide excellent care to. But she argues that it’s might be more effective to have a role that she has where she works with the nurse paramedic teams, train them, and keep everyone at really high standards.

So they can provide that oversight, but not necessarily going on every single transport. Because they do 5,000 transports a year and paying for a doctor to be involved in those would be e a lot.

[31:43] What She Wished She Knew that She Knows Now

Susan feels very lucky to be able to do what she gets to do. But when you do emergency medicine critical care, you have, by definition, a minimum of two bosses, two sets of faculty meetings, two sets of residency, education expectations, and so on.

It means that for a long time, Susan has worked twice as many nights, twice as many holidays, twice as many weekends because they have their own requirements.

Susan says it’s just tough to have two jobs, two bosses, and two schedules. And that’s why she says that sometimes it’s the worst thing she ever did. She still has time outside of the hospital, she still does have some control over her schedule.

But she works more nights, weekends, and holidays than many of her colleagues. And it is what it is. She has made this choice, and she’s happy with it.

She would have warned herself in the future that that’s what she was signing up for.

[33:52] How the ED-Based ICU Creates a Larger Footprint in Critical Care

But things are changing now in terms of the critical care landscape. One of the reasons that this has been an issue is because in contrast to all those other pathways she mentioned, emergency medicine is really the one specialty that doesn’t yet own their own true intensive care units. And this is starting to change.

Her colleagues at Michigan have created the EC3, which is a fantastic ED-based Intensive Care Unit. It’s a little bit different than your usual ICU where they don’t keep patients there long term. Some of their patients can be there for days, weeks, and months.

They just recently had a publication to show that they’re improving outcomes with this model. And Susan is optimistic that as this model takes off, more people see the great work that they’re doing. And that there will eventually be a role for emergency medicine ICU where they can control our own unit.

And so that’s her hope for the future that as emergency medicine starts to have a larger footprint in critical care, this will change.

[35:33] The Most and Least Liked Things About Being an Intensivist

She loves feeling that she actually made a difference. She finds it very gratifying to be able to take care of very sick patients.

And then conversely, sometimes in the intensive care unit, they have patients that they can’t save. Having had the training as an emergency medicine critical care physician, she’s been prepared to have conversations with families and the patients about their end of life care.

Either way, she is making a difference. So she gets to go home, feeling good about the care that she provided.

On the flip side, what she likes the least are definitely long hours. There are definitely times when she does these stretches and she gets tired. But it’s her choice which she says she’s happy to do. And that’s part of the reality of being a physician.

[38:09] Growing Old and Lacking Stamina in Critical Care

Susan says that a lot of people who do emergency medicine critical care end up spending a lot of their time in the ICU. And she knows a lot of people who have actually stopped doing emergency medicine altogether.

Part of the reason people love emergency medicine would be creating these relationships, being able to follow patients more longitudinally. It’s really satisfying once they get a taste of that. They’re coming at it from having the benefit of the emergency medicine training.

But there’s no way around the nights and the weekends. Some groups will say after you turn 60, you can stop being nice. And Susan admits it’s hard because you’re in constant bombardment of your thoughts with new information and new stimuli.

Ultimately, it’s about finding a spot that works well for them where they can eventually settle in there and see where they should be.

[39:57] Major Changes in the Field

Some people actually find it to be unsatisfying. This is because the downside is that you are sharing your patients with somebody else. You might leave in the evening with a particular idea of the trajectory and your colleague can change it. If you work in a good group, that’s fine.

But there are also some people that have expressed their discontentment with the idea of doing shift work. Because they want to have the sole responsibility for managing those patients.

Moreover, Susan is optimistic that critical care is going to become more integrated with time. For instance, the Society of Critical Care Medicine is looking to break down some of the barriers they had in critical care with these strict silos of the specialty.

So she sees that having more integration and more interdisciplinary involvement is going to be a good thing. But the downside is that it means that there’s more to learn, more to work on, and so the the knowledge never stops coming.

[41:32] Final Words of Wisdom

If she had to do it all over again, Susan would still have chosen to be an intensivist. All of the additional work, the additional training is so worth it. She might be a little tired and a little grumpy tomorrow afternoon, but she would still totally say the same thing. It has definitely been worth it.

What she wants to tell people who are doing emergency medicine and then want to do critical care is to go for it if you really want it. But you really have to want it.

If you’re not so sure, it’s not something that you should do. But if you really want it, then it is absolutely worth it. It is so satisfying to be with the sickest patients and work on them. You’d feel that you’ve really made a difference and that you’re improving their trajectory.